Cross-Post: The Third Option

This piece also appears at The Fat Nutritionist, by Michelle Allison. [I recommend her entire blog and consider her to be a personal hero and mentor. - Julia]

Two days ago, there were rumblings. First, I heard that the American Medical Association’s science council had advised them against declaring “obesity” a disease.

My initial feeling was one of mild surprise - hadn’t they declared it a disease already? I honestly didn’t know, but given the way our culture and our doctors treat fat people - as diseased, as a burden on society, and possibly doomed to explode of sheer fatness - I would’ve assumed they had.

My second feeling was lack of surprise that the science council, after examining the evidence, was recommending not to declare “obesity” a disease, because everyone knows that the diagnostic tool used for defining “obesity,” the Body Mass Index, is too blunt to be used in the absence of other health indicators, right?

And because everyone knows that there is a sizable population of healthy - by any definition - fat people, right?

No, not right. Wrong, in fact, because the next day the AMA went ahead and did exactly what their science council had advised them not to do, and declared that “obesity” - measured solely by a height-weight measurement, and defined by an imaginary line in the sand - to be a disease.

Here is why I have a problem with that.

First, what is a disease? Why do we define certain physical conditions as “diseases” and not others? You would think the answer would be “incontrovertible scientific evidence!”…and you would be wrong.

Diseases are defined partly on the basis of evidence that they impact a person’s ability to function, or cause suffering and death, but also partly (perhaps mostly) due to social and economic reasons.

What counts as a disease also changes over historical time, partly as a result of increasing expectations of health, partly due to changes in diagnostic ability, but mostly for a mixture of social and economic reasons…This has consequences for sufferers’ sense of whether they are…’ill’, but more concretely for their ability to have treatment reimbursed by health service providers.

Still, some doctors and obesity advocates said that having the nation’s largest physician group make the declaration would focus more attention on obesity. And it could help improve reimbursement for obesity drugs, surgery and counseling.

(Emphasis mine again.)

Imagine red, blinking, reindeer lights circling that quote. This is what I believe this new definition is about: defining a market (fat people who don’t want to be fat) and making it easier to sell things to them (drugs and surgeries and diet programs that promise to make them not-fat.)

If you can label a condition as a disease, it naturally follows that someone is going to develop a treatment for it, and people who suddenly realize they have an honest-to-goodness disease, and not merely a quaint variation on the human theme, are going to want to buy it. In this case, “people” represents a full third of the U.S. population. That’s over 100 million people, most of whom desperately do not want to be fat.
If you truly believe, in your heart of hearts, that “obesity” is a disease, then this is not a bad thing. In fact, it would seem to be a very, very good thing. I mean, fat is killing people! There’s an epidemic on, people! We’ve got to do something! Besides, people desperately want weight loss drugs, and they want them now. Pharmaceutical companies are simply trying to give people what they want. Capitalism in action. The system works!

And that might even be all well and good, provided the treatments actually work and do not harm people, and provided there are regulations in place to ensure that before releasing them to the public. But let’s look at a little history, shall we?

Historical medical treatments for fat include:

-Thyroid hormone given to fat people with normal thyroids around 1900 - stopped being used for this purpose after causing hyperthyroidism
-2,4-Dinitrophenol - withdrawn from the market in 1938 due to causing fatal hyperthermia
-Amphetamines - addictive, with many unpleasant side effects; brand name Obetrol was removed from the market in 1973
-Fen-phen - withdrawn from the market in 1997 after it was suspected of causing heart problems
-Redux - withdrawn from the market in 1997 after it was suspected of causing heart problems
-Meridia - withdrawn from the market in 2010 due to risk of cardiovascular events and strokes
-Orlistat - still on the market; causes oily butt leakage, kidney damage, vitamin malabsorption, and modest weight loss

Maybe someday someone will come up with a safe, effective weight-loss drug, but since this experiment has been going on for over 100 years now, I’m not holding my breath.

In announcing their decision, the AMA offered up two seemingly reasonable options: either we define “obesity” as a disease so that fat people are no longer blamed for their condition and can receive appropriate medical care…or we don’t, and the stigma and lack of treatments continue.

This is a false dichotomy. There is a third option that has been conveniently left out of the discussion, though a vocal minority of fat people have been arguing for it since the late 1960s: what if fatness is neither a disease nor a cause for blame and stigma?

What if there are so many different reasons people are fat that it’s impossible to boil it down to “personal responsibility” and moral failure?

What if being fat is just the way some of us are, and while we deserve appropriate medical care for whatever actual diseases we might have, we don’t need blame, shame, or a cure for our very existence?

What if fatness is not a disease, let alone an epidemic? What if fatness is part of human biodiversity - yes, a trait that intersects and interacts with disease, just as other traits like sex, skin colour, and height do - but not something to be eradicated at all costs?

Well, then we might have trouble selling things to people. For the weight loss industry, this would be a very big problem indeed.

Though I don’t share their goals, I would prefer that, for people who want to lose weight, safe and effective weight loss approaches were available. But those treatments should be optional, not mandatory, and they should not be the only treatments offered to fat people who go to the doctor for a medical issue. Losing weight should not be a prerequisite to receiving medical care.

Another problem is that we’ve been trying, with increasing desperation, to find those approaches for the last hundred years, and we have failed. People are not thinner. Attempting to lose weight may even cause some to get fatter over time. And the stigma attached to being fat has gotten worse.

I don’t think this stigma will be helped by calling fatness a disease. The doctors who seem to believe it will apparently don’t live in the same world I do, where HIV, Type 2 diabetes, mental illness, and lung cancer - to name only a few - are all officially recognized as diseases, and have all been incredibly stigmatized.

They also don’t seem to think doctors are taking “obesity” seriously enough, despite numerous reports from fat people of health care providers providing weight loss advice over and above actual care, and evidence of considerable weight bias among those who treat fat patients. Again - apparently the AMA doesn’t live in the same world I do.

In my world, my body and I are an indivisible unit. I am an embodied self, not a problem to be solved - and I happen to be fat. My fatness is part genetic heritage, part cultural identity, part vital organ. And it is not going anywhere, no matter who decides to call it a disease.